Pfizer Booster Clinic at North Penn High School

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I have received two doses of the Pfizer COVID-19 vaccine.I attest to receiving BOTH doses of vaccine prior to 6 months before my scheduled appointment (in example: if you received your 2nd dose on April 3, 2021 you are eligible for the 3rd dose after 6 months from that date (October 3, 2021)
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The CDC Advisory Committee on Immunization Practices’ (ACIP) recommends a booster shot of the Pfizer-BioNTech COVID-19 vaccine in certain populations and also recommended a booster dose for those in high risk occupational and institutional settings. I attest that I am :* This field is required.
65 years and older or a resident in long-term care settings who should receive a booster shot of Pfizer-BioNTech’s COVID-19 vaccine at least 6 months after my Pfizer-BioNTech primary series
50–64 years old with underlying medical conditions who should receive a booster shot of Pfizer-BioNTech’s COVID-19 vaccine at least 6 months after my Pfizer-BioNTech primary series
18–49 years old with underlying medical conditions who may receive a booster shot of Pfizer-BioNTech’s COVID-19 vaccine at least 6 months after my Pfizer-BioNTech primary series, based on their individual benefits and risks
18-64 years old who is at increased risk for COVID-19 exposure and transmission because of occupational or institutional setting who may receive a booster shot of Pfizer-BioNTech’s COVID-19 vaccine at least 6 months after my Pfizer-BioNTech primary series, based on my individual benefits and risks.
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Select an appointment time for vaccine at North Penn High School. PFIZER ONLY!* This field is required.** IF A TIME SLOT IS GRAYED OUT, IT IS NO LONGER AVAILABLE **
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Unique ID
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Vaccine Recipient Name* This field is required.
First Name
Middle Name
Last Name
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Driver's License or IdentificationPlease upload the front of your driver's license or ID card. **UPLOADING THIS IN ADVANCE WILL SAVE YOU TIME IN THE STORE**
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Max. file size: 10.6MB
Uploading this information in advance will expedite your registration on the actual clinic date.
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Vaccine Recipient Physical Address* This field is required.Please enter your full mailing address (i.e. 2020 Serenity Street, Lansdale, PA 19446)
Street Address
Street Address Line 2
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Email (to receive notification of appointment and informational documents)* This field is required.Enter an email address you check often.
I.e. jonathansmith@gmail.com
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Date of Birth* This field is required.If under the age of 18, parent / guardian must accompany the vaccine recipient to their appointment.
Date
Month
Day
Year
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Date of Birth* This field is required.Booster is approved only for 18+ currently. Please input date as MM/DD/YYYY (M= month, D = day, Y = year)
Ex. if born on January 11, 1956 put 1/11/1956
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Gender* This field is required.
Please Select
Please Select
Male
Female
Prefer not to Answer
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Race* This field is required.
Please Select
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American Indian or Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
Black or African American
White
Other Race
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Ethnicity* This field is required.
Please Select
Please Select
Hispanic or Latino
Not Hispanic or Latino
Unknown
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Vaccine Recipient Phone Number* This field is required.Cell phone number preferred
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Primary Care Provider NameWhat is the name of your family doctor or family doctor group? If unknown, write UNKNOWN, if you don't have one, write NONE
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Emergency Contact Name
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Relationship to Emergency Contact
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Phone Number of Emergency Contact
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Thank you for your interest in receiving the COVID-19 vaccine with Skippack Pharmacy.

For vaccine recipients, you are now going to answer a series of questions.

The following questions will help us determine if there is any reason you should not get the COVID-19 vaccine. If you answer “yes” to any question, it does not necessarily mean you should not be vaccinated. It just means you may need to consult with your doctor or healthcare provider prior to receiving your vaccine. Healthcare professionals or staff of the Skippack Pharmacy COVID-19 Vaccine Clinic will not provide any medical guidance on if you should or should not be receiving the vaccine. This is at the discretion of the vaccine recipient and their provider. If you are unsure about something, we suggest you call your doctor prior to coming to the clinic.

By clicking next, you acknowledge the above.
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COVID-19 Vaccine Screening QuestionsAdditional Information: https://www.cdc.gov/vaccines/covid-19/downloads/pre-vaccination-screening-form.pdf *Allergic Reaction Defined: This would include a severe allergic reaction [e.g., anaphylaxis] that required treatment with epinephrine or EpiPen® or that caused you to go to the hospital. It would also include an allergic reaction that occurred within 4 hours that caused hives, swelling, or respiratory distress, including wheezing.*
Yes
No
1. Are you feeling sick today?
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2. Have you ever had an allergic reaction* to: a component of a COVID-19 vaccine including either of the following: Polyethylene glycol (PEG), which is found in some medications, such as laxatives and preparations for colonoscopy procedures OR polysorbate, which is found in some vaccines, film coated tablets, and intravenous steroids OR a vaccine or injectable therapy that contains multiple components, one of which is a COVID-19 vaccine component, but it is not known which component elicited the immediate reaction.
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3. Have you ever had an allergic reaction* to another vaccine (other than COVID-19 vaccine) or an injectable medication?
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4. Have you ever had a severe allergic reaction* (e.g., anaphylaxis) to something other than a component of COVID-19 vaccine, polysorbate, or any vaccine or injectable medication? This would include food, pet, environmental, or oral medication allergies.
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5. Have you ever had a positive test for COVID-19 or has a doctor ever told you that you had COVID-19?
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6. Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19? [note: monoclonal antibodies does not include antibiotics that you would be prescribed and filled at a pharmacy]
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7. Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?
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8. Do you have a bleeding disorder or are you taking a blood thinner?
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9. Are you pregnant or breastfeeding?
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10. Do you have dermal fillers?
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11. I will let the vaccinator know if I answered YES to any of the above questions.
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1. Are you feeling sick today?
2. Have you ever had an allergic reaction* to: a component of a COVID-19 vaccine including either of the following: Polyethylene glycol (PEG), which is found in some medications, such as laxatives and preparations for colonoscopy procedures OR polysorbate, which is found in some vaccines, film coated tablets, and intravenous steroids OR a vaccine or injectable therapy that contains multiple components, one of which is a COVID-19 vaccine component, but it is not known which component elicited the immediate reaction.
3. Have you ever had an allergic reaction* to another vaccine (other than COVID-19 vaccine) or an injectable medication?
4. Have you ever had a severe allergic reaction* (e.g., anaphylaxis) to something other than a component of COVID-19 vaccine, polysorbate, or any vaccine or injectable medication? This would include food, pet, environmental, or oral medication allergies.
5. Have you ever had a positive test for COVID-19 or has a doctor ever told you that you had COVID-19?
6. Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19? [note: monoclonal antibodies does not include antibiotics that you would be prescribed and filled at a pharmacy]
7. Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?
8. Do you have a bleeding disorder or are you taking a blood thinner?
9. Are you pregnant or breastfeeding?
10. Do you have dermal fillers?
11. I will let the vaccinator know if I answered YES to any of the above questions.
Yes
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No
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Yes
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No
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Yes
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Yes
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Yes
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Yes
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Yes
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Consent (check each box below after reading and prior to signing the form)* This field is required.
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I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) Fact Sheet downloadable herein: https://www.fda.gov/media/144414/download. I may also request a physical copy of this in person. I have had a chance to ask questions that were answered to my satisfaction. I request the vaccine to be given to me or to the person named above, a minor for whom I represent that I am authorized to sign this Consent Form.
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I agree to stay in the vaccine administration area for fifteen (15) minutes or longer if indicated by the vaccine administrator after receiving my vaccine to ensure that no immediate adverse reactions occur.
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I, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless Skippack Pharmacy, its subsidiaries, divisions, affiliates, agents, officers, directors, contractors, and employees from any and all claims arising out of, in connection with, or in any way related to the administration of the vaccine(s).
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Please be aware that by entering the area of the pharmacy or clinic, you consent to your voice, name, and/or likeliness being used, without compensation, in photography or film and media, and you release Skippack Pharmacy, its successors, assigns, and licensees from any liability. I will inform a member of the staff if I wish not to be included in any photos, film, or media.
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I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) Fact Sheet downloadable herein: https://www.fda.gov/media/144414/download. I may also request a physical copy of this in person. I have had a chance to ask questions that were answered to my satisfaction. I request the vaccine to be given to me or to the person named above, a minor for whom I represent that I am authorized to sign this Consent Form.
I agree to stay in the vaccine administration area for fifteen (15) minutes or longer if indicated by the vaccine administrator after receiving my vaccine to ensure that no immediate adverse reactions occur.
I, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless Skippack Pharmacy, its subsidiaries, divisions, affiliates, agents, officers, directors, contractors, and employees from any and all claims arising out of, in connection with, or in any way related to the administration of the vaccine(s).
Please be aware that by entering the area of the pharmacy or clinic, you consent to your voice, name, and/or likeliness being used, without compensation, in photography or film and media, and you release Skippack Pharmacy, its successors, assigns, and licensees from any liability. I will inform a member of the staff if I wish not to be included in any photos, film, or media.
Check each box
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Check each box
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I understand that I will be receiving the COVID-19 vaccine at no cost to me; however, I will provide my insurance information to the Skippack Pharmacy team for administration.

If you are enrolled in Medicare, it is required to provide your Medicare Part B Card (red, white, and blue card). Your Medicare Advantage or Part D plan is not required. If you are not enrolled in Medicare, click "NEXT" through each of those steps and please enter your commercial prescription coverage insurance (card will say RX on it somewhere, otherwise you are looking at the wrong card) If you do not have Medicare B or prescription insurance, please bring your social security card and click "NEXT" through each of the steps.

Uploading the image of the card(s) in advance will speed up the registration process for you otherwise, it will be needed at registration.
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Medicare Card (65+ or Disabled), click "NEXT" if not applicableFor seniors 65+ or with disability, please upload a front copy of your Medicare B card (red, white, and blue). Move onto the next step if you do not have a Medicare card or have difficulty uploading it. **Having this completed will expedite registration.**
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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This is what a Medicare B Card Looks Like, click "NEXT"The highlighted beige field is your Medicare number we'll need on the next page.
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If on Medicare, Please enter Medicare Number on RED, WHITE, BLUE Medicare card as shown in previous image. If this does not pertain to you, skip this step by inputting "N/A" and click "NEXT"I.e. 1EG4-TE5-MK72
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Prescription RX Insurance CardFor anyone with a prescription RX insurance card, please upload the front of the image herein. This card must have the words RX BIN on it as your prescription card. Move onto the next step if you do not have a Prescription card or have difficulty uploading it. **UPLOADING THIS IN ADVANCE WILL SAVE YOU TIME IN THE STORE**
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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This is what a Prescription RX Card Looks Like **Has RX BIN on it**, click "NEXT"Notice how their is a logo or letters on it somewhere that says the letters "RX" --- if it doesn't have RX written on it, you are likely looking at your medical card. We do not need that.
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On the prescription insurance card, the BIN number is blanks The PCN is The ID is The Group is If you don't see any of these numbers on your prescription card, you are likely looking at your Medical Card. Your prescription card should say "RX" on it somewhere. You can skip this; however it may delay your on-site registration on the day of. Click "NEXT" if you do not have insurance.
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If you DO NOT have active prescription insurance, please input your Social Security Number, this will be used to bill the CARES Act for administration costs of the vaccines.
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Which arm would you like to receive the vaccine?Please inform the vaccinator which option you select.
Left
Right
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Signature of Person to Receive Vaccine* This field is required.
Clear
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Date Signed* This field is required.
Date
Month
Day
Year
Should be Empty: